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Address______________________________________________________________

How do you get there now?______________________________________________

Where do you go?______________________________________________________

Address_______________________________________________________________

How do you get there now?_______________________________________________

SECTION C:  FUNCTIONAL ABILITIES

Do you use any of the following mobility aids or specialized equipment?

CanePortable Oxygen

CrutchesPowered Wheelchair

WalkerManual Wheelchair

Service AnimalLong White Cane

Power ScooterOversized Wheelchair

Leg BracesProsthesis

Other, Specify______________________________

WITHOUT THE HELP OF SOMEONE ELSE, CAN YOU…

Ask for and understand written or spoken instructions?

AlwaysSometimesNever Not Sure

Cross the street?

AlwaysSometimesNeverNot Sure

Stand for 10 minutes if there is no place to sit?

AlwaysSometimesNeverNot Sure

Step on and off a sidewalk from the curb?

AlwaysSometimesNeverNot Sure

Walk up and down three (3) twelve (12) inch steps?

AlwaysSometimesNeverNot Sure

Stand on a moving bus holding onto a handrail?

AlwaysSometimesNeverNot Sure

Find your own way to the bus stop if someone shows you once?

AlwaysSometimesNeverNot Sure

Transfer from one fixed route bus to another bus?

AlwaysSometimesNeverNot Sure

Walk up and down three (3) twelve (12) inch steps with handrail?

AlwaysSometimesNeverNot Sure

Page 6

Revised 6/14/07

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